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Strangers or Friends?: Strangers or Friends? A Proposal for a New Spirituality-in-Medicine Ethic March 30, 2005 Farr A. Curlin, MD The University of Chicago Daniel E. Hall, MD, MDiv Duke University and The University of Pittsburgh
Setting the Stage:Religion and Health: Setting the Stage: Religion and Health Research blossomed in last 20 years Now over 2000 peer-reviewed articles Medicine, Sociology and Psychology What was once an obscure field is developing respect and stability Even a skeptical NIH consensus panel agrees that religious attendance is associated with longer life.
With Popularity Comes Controversy: With Popularity Comes Controversy Debate focuses primarily on the empirical merits of the data. Subject matter polarizes people Proponents Harold Koenig, David Larson Opponents Richard Sloan, Emile Bagiella Deep Commitments on both sides
A Level Deeper: A Level Deeper ‘Efficacy” of religiousness is almost irrelevant to a number of philosophical concerns —some of which we will explore this evening. Language of Spirituality is “fundamentally ambiguous and flawed term that can be made to mean anything.” Suggests that this free-form use of spirituality may, in fact, obscure the reality that “what every person does have is an underlying (often unconscious and unquestioned) system of meaning and value.” Scheurich, N. (2003). "Reconsidering Spirituality and Medicine." Academic Medicine. 78: 356-360.
“Without attention to the epistemological matters of conceptualizing and operationalizing ‘religion’ in meaningful ways, no amount of methodological and analytical sophistication will be sufficient to generate meaningful findings” Levin, J. S., and H. Y. Vanderpool. 1987. Is frequent religious attendance really conducive to better health? Toward an epidemiology of religion. Soc Sci Med 24(7):589–600.: “Without attention to the epistemological matters of conceptualizing and operationalizing ‘religion’ in meaningful ways, no amount of methodological and analytical sophistication will be sufficient to generate meaningful findings” Levin, J. S., and H. Y. Vanderpool. 1987. Is frequent religious attendance really conducive to better health? Toward an epidemiology of religion. Soc Sci Med 24(7):589–600.
Scheurich’s Conclusion: Scheurich’s Conclusion Medicine should rely on a secular philosophy “that is neutral…with respect to religion.
Can Physicians’ Care Be Neutral Regarding Religion?: Can Physicians’ Care Be Neutral Regarding Religion? NO Hall, D. E. and F. Curlin (2004). "Can physicians' care be neutral regarding religion?" Academic Medicine. 79: 677-679.
Humane Medicine: Humane Medicine Focus on spirituality and religion is often an attempt to recover a more humane medicine. Religion and/or spirituality denotes holding intently some system of meaning and value. Conflict between proponents and opponents is not so much a conflict about facts as a conflict about these values—conflict about the proper ends of medicine.
Value Neutrality: Value Neutrality To resolve this conflict, critics like Scheurich suggest that religion and science are immiscible, and should be kept separate. As a science, medicine should be guided by universal or neutral values derived from reason alone without appeal to particular beliefs –religious or otherwise.
Foundationalism: Foundationalism Foundation of “universal” knowledge Accessible to all people Lock away particular, individual convictions Empirical observation and the application of reason Extremely powerful at answering particular types of questions. Part and parcel with modernity But it wasn’t always so.
The Bad News: The Bad News Foundationalism is dead or dying. Objectivity, as such, doesn’t exist. Living through a revolution of epistemology. Trust, not proof, plays a much larger role in our systems of knowledge than we like to admit. Physics text book v. repeating Newton’s experiments.
Neutrality Is Never an Option: Neutrality Is Never an Option At the root of each worldview or philosophy (sacred or secular) there are specific commitments from which we cannot be divorced. It remains possible to engage in conversation across large philosophical divides and to respect differing perspectives, but neutrality is never an option.
Unmediated Knowledge: Unmediated Knowledge This is the way scientists are trained to think This is the way our culture is trained to think
Unmediated Knowledge: Unmediated Knowledge But it just isn’t possible
Mediated Knowledge: Mediated Knowledge None of us are a blank slate All knowledge is mediated through some interpretive lens Sunrise is different for: Aquinas Copernicus Einstein
Mediated Knowledge: Mediated Knowledge However, the lens is often invisible—hidden by unconscious assumptions Yet, nonetheless, the lens constrains both the possible questions and the possible answers Degree of certainty is contingent on how much we trust the lens.
Multiple Lenses: Multiple Lenses More than one lens shapes our knowledge of the world. Physician Scientist Husband/Father American Woman/Man Black/White
Compound Lenses: Compound Lenses Both the number and the order of the lenses matter.
Why does this matter?: Why does this matter? These lenses that shape our knowledge of the world are what make up our worldview. The values that shape our commitments regarding the proper ends of medicine—the values at the center of the controversy about religion and medicine—those values grow from our worldviews.
Why does this matter?: Why does this matter? Religion is one powerful source for worldview. “A comprehensive, self-referentially complete interpretation of the human condition that does not require reference to any external narrative or tradition.” (Hall, DE, Koenig HG, Meador KG. Conceptualizing "religion": How language shapes and constrains knowledge in the study of religion and health. Perspectives in Biology & Medicine. 2004;47(3):386-401.) Secular worldviews are similarly self-referentially complete interpretations of the human condition that do not require reference to external narratives or tradition.
Wisdom and Character: Wisdom and Character Secularism is not neutral regarding religion We would never expect anyone, theist or atheist, to be neutral regarding religion. But an unattainable “neutrality” will not help physicians to navigate the turbulent waters of religion and medicine. What is needed is wisdom and character—but the formation of these virtues is not clear.
Transition: Transition How should physicians address religion and spirituality in the doctor-patient relationship? an ongoing moral debate . . .
Outline: Outline Curlin F, Hall DE. Strangers or Friends? A proposal for a new spirituality-in-medicine ethic. Journal of General Internal Medicine. 2005 (in press). Review the current debate Critique its terms and ideal Propose new terms and new ideals Anticipate some objections
Current Debate: Current Debate Agreement: Physicians should be attentive to and respectful of patient religion But what else? Active vs passive inquiry? Clarify implications? Validate? Take into account? Support or challenge? Suggest different understandings? Persuade? Proselytize?
“Spiritual Inquiry”: “Spiritual Inquiry” Proponents: Spiritual Inquiry Treats patient as a person Builds rapport Discerns relevant factors Critics: Spiritual Inquiry Is misdirected and meddlesome Invades privacy, crosses professional boundaries Raises threat of coercion
A shared conceptual framework: A shared conceptual framework Dialogue regarding religion is: A therapeutic technique Applied by one stranger to another (Alvin Feinstein: Medicine has become a mere “technical performance.”) Three relevant questions for moral inquiry, and their answers.
Question #1: Are physicians competent?Answer: No: Question #1: Are physicians competent? Answer: No Why important? - “First act of kindness” How judged? – Prof. training/certification Why not competent? No professional training If some training, still too specialized Even if competent, still relatively incompetent Insufficient time
Competence . . .: Dangers of incompetence: Erroneous ideas Ill-conceived recommendations Harm to patients Therefore: Refer to religious professionals Competence . . .
Question #2: Is autonomy threatened?Answer: Yes: Question #2: Is autonomy threatened? Answer: Yes Why is autonomy important? Patient have a right to “find their own solutions” Without “undue influence” Why is autonomy threatened? “Aesculapian” mystique Unequal power Patients are unwitting participants
Autonomy . . .: Resulting dangers: Imposition Coercion Therefore: “Take note” but don’t “take on.” Don’t expound Don’t recommend or critique Unless . . .religion conflicts with “rational, evidence-based medicine.” Autonomy . . .
Question #3: Will physicians maintain neutrality regarding religion?Answer: Probably not: Question #3: Will physicians maintain neutrality regarding religion? Answer: Probably not Why is neutrality important? Professional boundary – patients’ seek medical expertise Religion and science – immiscible languages Religious opinions professionally unregulated Why is neutrality threatened by dialogue? How could it not be?
Neutrality . . .: Neutrality . . . Therefore If you inquire, don’t take sides “Separation of church and medicine”
Summary: three ideals: Summary: three ideals Competence Autonomy Neutrality
Outline: Outline Review the current debate Critique its terms and ideal Propose new terms and new ideals Anticipate some objections
A critique and a proposal: A critique and a proposal Suppose dialogue regarding religion is Not a technique between strangers But a moral discourse governed by an ethic of friendship. Consider the former three questions Propose alternates
Competence vs. Wisdom : Competence vs. Wisdom Dialogue is not a technique Patients don’t seek certified spiritual tx. Example: breast cancer . . . what to do? Physicians must dialogue to seek patients’ good “Practical wisdom” (phronesis) is required Cannot be gained solely from professional training Mediated through experience, tradition Ex: Osler’s clinical judgment Professional ≠ Wise
Competence vs. Wisdom (cont): Competence vs. Wisdom (cont) Universal technique ≠ traditional wisdom Professional compartmentalization is ultimately dehumanizing Note counter-movements in medicine Note patient and physician dissatisfaction
Autonomy vs. Respect : Autonomy vs. Respect What about moral persuasion? Ex: “Quit smoking”, “Hang in there” MDs use unequal power judiciously A double standard and secular bias Recommendations are prima facie violations Challenges are ethically obligatory Counter secular bioethics − No decisions occur in a vacuum Patient: “I understand the options, Doc, but what should I do?” – requires moral counsel
Autonomy vs. Respect (cont): Autonomy vs. Respect (cont) Moral counsel: a privilege and responsibility In an ethic of friendship: Discourse . . . Seeks to clarify and promote the patient’s flourishing Does so with deep respect Always walks a fine line Requires trust and wisdom Is what physicians do Neither coercion nor silence
Neutrality vs. Candor : Neutrality vs. Candor Problematic assumption #1: Physicians can and should be neutral regarding religion. Neutrality not possible No “view from nowhere” “Spirituality” does not bridge disagreements re: religion For devout, neutrality = unfaithfulness
Neutrality vs. Candor : Neutrality vs. Candor Problematic assumption #2: Religion is private and should not influence the professional sphere. Weber: Modernity fosters separation of “spheres.” Christianity, Judaism, Islam make totalizing claims Put God first in all of life Resist cultural pressure to privatize commitments Neutrality is rooted in secularism. Secularism is not neutral regarding religion
Neutrality vs. Candor : Neutrality vs. Candor What then? Not professional endorsement of a particular religion Not physician neutrality Address disagreements with respect and candor. Seek a (peaceable) accommodation Does not mean tell all to all, but does mean candor and clarity ( . . .wisdom, respect). Requires dialogue!
Outline: Outline Review the current debate Critique its terms and ideal Propose new terms and new ideals Anticipate some objections
Objections: Objections Pandora’s box “I don’t want my doctor to talk to me about religion!” Discourse may generate conflict
Where do we go from here? : Where do we go from here? Can medical education form wisdom? Diminishing mentorship Diminishing discourse Mentorship in wisdom requires virtue. Aristotle: Virtue makes us aim at the right target [i.e. the patient’s good], and phronesis makes us use the right means.” The “hidden curriculum” – anti-virtue No magic bullet Moral discourse likely to be sustained by secular and religious communities that preserve a vibrant tradition of moral discourse.
Summary: Summary A simple approach An ethic of friendship Wisdom, respect, candor Neutrality not an option Discourse often necessary
Questions: Questions

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